When a doctor orders routine prostate screening for an 80-year-old man -; As doctors often do -; A dramatic yellow alert pops up in the electronic health record with dire warnings.
It flashes: “You are ordering a test that no guidelines recommend. Screening with PSA can lead to the loss of diagnostic and treatment procedures. If you proceed without justification, the unnecessary test will be noted in the health record.”
It was a ploy to see if Northwestern Medicine investigators could move the needle on the stubbornly persistent practice of ordering unnecessary screenings for older adults. Doctors got the message.
Results, published in February. 6 inches History of Internal MedicineSignificant reductions in screening for prostate cancer and urinary tract infections have been observed.
After 18 months of providing warnings to 370 physicians at 60 Northwestern Medicine clinics, unnecessary testing was reduced by 9% in the PSA intervention group and 5.5% in the urine testing intervention group. However, there was only a small change in blood sugar overtreatment, which may account for potential harm. Half of the physicians received the warning, the other half did not.
To our knowledge, this is the first study to significantly reduce all unnecessary tests or treatments studied using point-of-care precautions. We believe that incorporating elements such as focusing on potential harm, sharing social norms, and promoting feelings of social responsibility and reputational concern lead to the effectiveness of these messages.”
Dr. Stephen Purcell, principal investigator, is a professor of medicine at Northwestern University Feinberg School of Medicine and a Northwestern Medicine physician.
Several recent trials that tried to reduce test overuse using interventions delivered to physicians through electronic health records were not particularly successful in changing physician behavior, Purcell noted.
“But if physicians find compelling messages that clinicians can deliver through the electronic health record when placing their orders, it could be a simple way to improve care and could easily be implemented in large health systems,” Purcell said.
Harm from unnecessary screening and overtreatment
Screening a man age 76 or older for prostate cancer can lead to additional treatment that could cause him more serious health problems than just living with an indolent cancer.
Still, a man’s primary care physician will often order a PSA test to screen for prostate cancer. The same is true for women age 65 and older who are being screened for urinary tract infections without symptoms. Doctors also treat diabetes with hypoglycemic agents in patients age 75 and older.
Low-cost screening and overuse of unnecessary care is a problem in American health care, especially for older adults.
“These are screening practices that people have adopted without good evidence,” Purcell said.
“If a man can’t live another 10 or 15 years because of his age, you’re not going to save his life from prostate cancer by screening him, but you’re exposing him to the potential harm of treatment,” Purcell also said. Director of the Primary Care Innovation Center at Feinberg. Treatment may include surgery or radiation therapy that can cause urinary incontinence or urinary symptoms, disrupt sexual function, or cause rectal bleeding.
“What’s right for a 68-year-old may not be right for a 75- or 85-year-old,” Purcell said.
Screening for urinary tract infections in women age 65 and older can also be harmful, if they are not experiencing any symptoms.
“These asymptomatic urinary tract infections are common in older women, but there’s no evidence that you can improve a woman’s health with antibiotics,” Purcell said. Antibiotics, however, can cause allergic reactions, diarrhea and antibiotic resistance, which can make future bacterial infections difficult to treat.
Also, treating very low blood sugar levels in older adults with drugs such as insulin or sulfonylureas puts older patients at risk of dangerous low blood sugar events.
But doctors and patients resist changes in blood sugar interventions. “We teach patients to try to control their blood sugar, even when it gets to a point where it’s safe to have slightly less controlled blood sugar,” Purcell said. “It’s hard to convince patients and doctors to change their goals.”
The next step in the research and other ongoing studies are examining whether similar approaches can be used to improve quality of care in other areas where treatments may be overused, such as opioids, sleeping pills and drug combinations that can cause harm.
Among other authors, Lucia C. Petito, Ji Yong Lee, Daniela Meeker, Jason N. Doctor, Noah J. Goldstein, Craig R. Fox, Theresa A. Roe, Dr. Jeffrey A. Linder, Ryan Chmiel, Yao Amofa Peprah, and Tiffany Brown.
The title of the article is “Reducing Overutilization of Care for Elderly Patients Using Professional Standards and Accountability.”
The research was supported by National Institute on Aging of the National Institutes of Health Award R33AG057383.
Purcell, SD, etc. (2024). Reducing the overuse of care for older patients using professional norms and accountability. History of Internal Medicine. doi.org/10.7326/m23-2183.